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Mini Posterior Approach

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Title: Mini Posterior Approach


1
Minimally Invasive Total Hip Arthroplasty
Mini Posterior Approach Mini Anterior
Approach MIS 2 Incision Approach
Frank R. Ebert, M.D. Union Memorial Hospital
2
Movement Toward Less Invasive Surgery
3
Background
  • Mini - Incision Approach Developed Over 6
    Years
  • Progressively Decreased Incision To 6.0 - 8.5 cm
  • Over 600 Patients

4
Modified Instruments Retractors
  • Charnley
  • Holman
  • Blunt
  • Sharp
  • Skin Protector

5
Modified Instruments Cup Inserter
Old
New
Prototype
6
MIS Hip Instruments
7
Set - Up Level Table
8
Incision
  • Landmarks
  • Center Incision
  • Avoid Being
  • Proximal
  • Varus Hips
  • Easier

9
Exposure
Head
  • Posterior Approach
  • Capsular Incision
  • Special Retractors

10
Osteotomy Remove Head
11
Acetabular Preparation
  • Labrum Excised
  • Osteophytes
  • Removed

12
Acetabular Preparation
  • Labrum Excised
  • Osteophytes
  • Removed

13
Acetabular Preparation
  • Beware Inferior
  • Skin Edge
  • Avoid Posterior
  • Reaming

14
Acetabular Component In Place
15
Femoral Preparation
  • IV Heparin
  • Protect Skin
  • Avoid Posterior
  • Stem Position

16
Femoral Preparation
Control Broach Rotation
17
Femoral Preparation
Watch Skin Proximally
18
Femoral Preparation
  • Proximal Fill
  • Anteversion

19
Components Implanted
  • Trilogy Cup
  • UHMWPE
  • Liner
  • VerSys
  • Fiber Metal
  • Taper Stem

20
Capsular Closure
  • Piriformis
  • Conjoined
  • Tendon

21
Skin Closure
6.0 8.5 cm
22
X-Ray Position
23
Patient Selection
  • Start With
  • Ideal Patient
  • Women Easier
  • Than Men
  • Up To 320
  • Pounds

24
Observations
  • Dislocations 5
  • Infections 0
  • Nerve Palsy . 0
  • Transfusion Rate 15
  • Operative Time 39.5 minutes
  • (Skin to Skin)
  • Length Of Stay 3 days

25
MINI-APPROACH THA-ANTERO-LATERAL
  • Incision Length between 3 to 5 inches
  • Incision Location is Key
  • Split Medius and Minimus tendons with or without
    an anterior trochanteric wafer
  • Expose the acetabulum in a standard fashion-lit
    retractors help

26
MINI-APPROACHTHA ANTERO-LATERAL
  • Acetabular Insertion facilitated by dog leg
    inserter-avoids vertical position
  • Femoral exposure facilitated by incision
  • Closure includes a capsular repair

27
Incision
28
Incision
29
Incision
30
Incision
31
Incision
32
Incision
33
Acetabular Preparation
34
Acetabular Preparation
35
Acetabular Preparation
36
Acetabular Preparation
Avoid Vertical Cup Placement
37
Cup Inserter
Advanced Prototype
38
Cup Inserter
39
Cup Inserter
40
Femoral Preparation
Femoral Canal
41
Femoral Preparation
42
MINI-APPROACHTHA ANTERO-LATERAL
  • Workhorse approach in last 300 cases
  • Implants included trilogy cup and a proximally
    beaded or fiber metal taper midcoat stem

43
MINI-APPROACHTHA - ANTEROLATERAL
  • Length of Stay 3 days
  • Length of Surgery 60 to 90 minutes
  • Post-op Hip Precautions for 6 weeks
  • Post-op wt bearing partial for first four weeks

44
MINI-APPROACHTHA - ANTEROLATERAL
  • Workhorse approach for my last 300 patients
  • No dislocations
  • No fractures
  • 15 cases of DVT
  • 1 PE non fatal
  • No infections

45
Potential Advantages
  • Decreased Bleeding
  • Decreased Operative Time
  • Decreased Length of Stay
  • Faster Rehab
  • Decreased Pain
  • Increased Patient Satisfaction
  • Improved Cosmesis
  • Physician Practice Marketing

46
Potential Disadvantages
  • Experience Required
  • Difficult To Teach
  • Avoid Vertical Cup Placement
  • Avoid Posterior Canal Reaming
  • Avoid Skin Abrasion

47
Techniques in Minimally Invasive Hip SurgeryMIS
2 Incision Approach
  • Frank R. Ebert, M.D.
  • Asst. Chief Dept. of Orthopedics, Union Memorial
    Hospital
  • Asst. Professor Johns Hopkins University, School
    of Medicine
  • Baltimore, MD

48
What is minimally invasive hip surgery and why
would you do it?
49
Minimally Invasive Total Hip Surgery Advantages
  • Smaller incision utilized
  • Decreased hospital stay
  • Shorter recovery time
  • Much faster physical therapy
  • More stability because of less soft tissue
    dissection

50
Its not about the size of the incision!
MIS Instruments
51
Why I Became Interested in MIS
  • Orthopaedic arthroplasty patients are the only
    remaining inpatients
  • Desire to improve the total hip critical pathway
  • Realized the two incision approach was possible
    from cadaver studies
  • Combination of the two incisions was very
    familiar because of my trauma background

52
MIS Total Hip Surgical Development
  • Cadaveric studies over a 10 year period by Dana
    Mears Investigational Centers
  • Surgical Technique evolving _at_ the clinical sites
  • Surgical instruments developed by Zimmer to
    facilitate surgery
  • First surgical cases done by Drs Berger,
    Duwelius, Tanzer, Ebert, Hartzband _at_ MIS sites
  • Several newer instruments and ultimately implants
    will evolve for the MIS technique

53

MIS 2 Incision Technique
Anterior Incision
Posterior Incision
54
MIS Surgical Technique Anterior Approach
  • Anterior incision 4-5cm.
  • Through the first incision with modified
    instruments the femoral head neck are removed
  • The Trilogy cup liner are inserted after
    special modified reamers have prepared the
    acetabulum

55
Anterior Incision
Radiographic Landmarks
Anatomical Landmarks
56
Anterior Landmarks Incision
57
MIS Surgical TechniquePosterior Approach
  • Posterior incision 2-3cm.
  • Preparation of femoral canal reaming,broaching
    stem insertion
  • Versys Fiber Metal Midcoat Prosthesis utilized
    initially
  • Versys Beaded Fullcoat is the stem of choice
    Procedure is stem dependent

58
Surgical Technique
Femoral Starting Point
59
Visualization of Starting Point With Flouroscopy
Lateral
AP
IM Femoral Nail
60
Posterior Incision
61
(No Transcript)
62
Union Memorial MIS Data
  • 30 consecutive MIS procedures
  • 5 Proximally Coated
  • 25 Fully Coated
  • IRB protocol completed
  • Trend toward decreased hospital stay
  • Postoperative hip precautions
  • Majority of patients released within 48 hours

63
MIS HIPPrimary Diagnosis
Union Memorial Hospital Baltimore, Maryland
1/10/03
64
MIS HIPDemographics
Union Memorial Hospital Baltimore, Maryland
  • Average Age
  • Male 58 years
  • Female 61 years
  • Average Weight
  • Male 182 lbs
  • Female 141 lbs

1/10/03
65
MIS HIPOR Times
Union Memorial Hospial Baltimore, Maryland
Minutes
Patient
2/4/03
66
2 Incision MIS Total Hip Arthroplasty
  • Average Length of Stay
  • First 10 cases average 3.5 days
  • Last 10 cases average 1.8 days

67
2 Incision MIS Total Hip Arthroplasty
  • Complications Fractures
  • 4 Intra-op fractures
  • 1 required revision from a midcoat to a fully
    porous revision implant case 10
  • 2 required cabling case 8,16
  • 1 required no treatment case 2

68
2 Incision MIS Total Hip Arthroplasty
  • Complications Dislocations
  • none

69
2 Incision MIS Total Hip Arthroplasty
  • Complications
  • Thigh Numbness 5 cases
  • DVT/PE 0/0
  • Infection none
  • Wound Problems 3 cases
  • Leg Lengtheningone-half inch - none

70
MIS HIPHarris Hip Scores
Union Memorial Hospital Baltimore, Maryland
N15
N20
N30
N30
9/11/02
71
C.K. Case 1 DOS 2/10/02
72
Intraoperative Verification of Stem Cup Position
73
J.R. Case 4 DOS 2/25/02
74
B.M. Case 6 DOS 3/20/02
75
R.A. Case 8 DOS 3/30/02
76
S.K. Case 9 DOS 4/20/02
77
Insertion of Femoral Stem through Posterior
Approach
78
Postoperative Hip Stability
79
MIS Questions
  • Cost savings may be significant
  • Can surgical technique reliably be reproduced by
    other surgeons?
  • Can hip surgery ultimately be done in an
    outpatient setting?

80
MIS Trends
  • Patients tolerating the procedure better than the
    traditional procedure
  • Hospital stay has been shorter than our 4 day
    average stay with conventional THR
  • Recovery is quicker PT same day
  • Hip precautions are virtually nil with two
    incision technique

81
MIS Conclusions
  • Its about the techniquenot size of incision
  • Better surgical interval
  • Less Dissection
  • Smaller incisions are good
  • Instrument dependent evolving
  • Training is critical more difficult than mini
  • Surgical procedure is good, safe and reproducible
    in our institution with 30 cases performed
  • Need long term F/U

82
Thank You
Union Memorial Hospital Johnston Professional
Building Baltimore, Maryland
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